Canada’s Burning Reader Response

“Canada’s Burning! Media myths about universal health coverage, ” by Theodore Marmor and Kip Sullivan, falsely assume that what works for Canadian health care consumers is relevant in the U.S. and that bashing the media messenger will disprove the facts and opinions that journalists report. And they downplay and deny the well known but inconvenient (to U.S. advocates of a single payer health care financing system) evidence that the Canadian single payer system is a mess.

Marmor tries to make the case that poor, dumb, unread Americans are being taken in by newspaper and broadcast reporters who don’t follow the health economics literature. True, few reporters get beyond Editor & Publisher’s help wanted ads. But they apparently write articles that the scholarly Marmor is willing to quote. After all, their work is original, not based on Internet research. Also, it’s clear that some academics and health writers don’t comprehend the literature they read. My impression is that most journalists are being taken in by a few academics and politicians who want to nationalize our health care system. But, then, I read more than Health Affairs, USA Today and The New York Times.

It would take another article to correct the authors’ distortions and selective omissions. (I give the article an F for content and a D for effort.) But I would like to make a few points. Comparing the health care systems of Canada, the U.S. and other countries is interesting but not very meaningful. This is because our cultures, political systems, lifestyles, markets, histories and demographics are so different, even in North America. To say that public debate and media attention makes Canada’s single payer system more democratic than the same do for Medicare, Medicaid and privately-insured health care in the U.S. ignores the fact that more than half of the U.S. health care system is nationalized, socialized medicine. How Canada’s parliamentary system operates is much different than ours does. For one thing, Canada and the U.K. have dictatorships that are elected every four or five years, and politicians are much more insulated from public opinion and pressures by party discipline than our representatives are. U.S. legislators, on the other hand, are much more responsive to groups representing sellers (doctors, hospitals, HMOs) than to consumers. Bribes, legal or not, work extremely well in this country. Yet, consumers do have a say in our system, witness the current debates over the patients bill of rights and prescription benefits for Medicare beneficiaries.

Many of the studies the author quotes are flawed by poor statistical designs, biased interpretations and hidden agendas. There is no such thing as “scientific evidence” regarding health treatment outcomes in the U.S. and Canada, but there are unscientific studies like those summarized by Marmor.

The authors cite the higher administrative costs health consumers pay in the U.S. vs. those paid by Canadian taxpayers. These numbers are misleading, because they don’t spell out the value added by informing consumers (marketing, advertising, employers), giving consumers choices of health plans (available to only a few Canadians), giving providers and insurers incentives to improve their quality and productivity (How many Canadian docs work 12 hour days?), invest in new technology (lagging terribly in Canada) and attract investors who finance advances in health care delivery and medical research.

Finally, Marmor chooses to ignore the failures of socialized medicine in the U.S. : Medicaid, Medicare, states’ mental health programs. When states were responsible for mental health, they put the mentally ill in psychiatric hospital concentration camps. Patients were tied down and drugged into submission. The system was abandoned in the 1970s.

It’s easy to carp about our very politicized and democratic health care system. Fortunately, millions of health care workers, bureaucrats, insurers and, yes, even politicians, scholars and journalists, work every day to deliver better care to patients. The challenge is to create a system that will work in America, not to transplant Canada’s failures and socialistic culture to this country. We can do this only with a dynamic, decentralized, privatized and market-oriented health care system.

One does not “read” a letter as jumbled and incoherent as Donald Johnson’s. One investigates it, much as one investigates the scene of an accident, picking through mountains of irrelevant or inscrutable debris in order to find a few shards of evidence that convey some meaning. Our recommendation to readers is to turn their heads away from the accidental word spill suffered by Mr. Johnson. It is not pretty, and there’s little to learn from poking through it. The second paragraph was especially ugly – words strewn everywhere.

Mr. Johnson’s main premise, it appears, was that Canada’s health care system “is a mess.” We have picked through the accident scene and could find nothing supporting this premise – not one anecdote, not one study, nothing other than Mr. Johnson’s apoplectic assertion to that effect. (We think his accidental word spill may have been caused by writing way too fast while holding his breath, possibly due to apoplexy.) Our paper, on the other hand, cited polling and scientific data to support our belief that Canada’s system is a good one that Americans can learn from. We believe that most sentient beings, when confronted with a choice between an apoplectic assertion on the one hand and polling and scientific data on the other, will agree that the latter trumps the former any day.

Mr. Johnson attempted to rebut the scientific data we offered with an example of the know-nothing mind-set that has animated extremist (and ineffective) American fringe parties throughout America’s history. Mr. Johnson asserted, “There is no such thing as ‘scientific eviden’ regarding health treatment outcomes in the US and Canada. . . .” By this nihilistic logic, no two human experiences or systems may be compared if they occur in different places on the globe, no matter how similar the societies in those places may be. Thus, for example, the fact that all other industrialized nations have lower prices for patented drugs that the US does is irrelevant according to Mr. Johnson’s know-nothing philosophy of science. You, fool that you are, may think the difference can be explained by the fact that all non-American industrialized countries have price controls on drugs. But Mr. Johnson knows better. He knows, for example, that the Germans speak German and drink funny beer, while Americans speak English and drink Miller Lite, and that these hundreds of other differences he could think up if you asked him render any information about German price controls on drugs irrelevant to the debate in the US about how to reduce drug prices.

Despite Mr. Johnson’s brilliant logic and the mass of relevant data he marshalled, we are not yet prepared to abandon science. We cling to the old-fashioned notion that it is possible to measure the quality of medical care given to particular types of patients, say prostate surgery patients, in different parts of the globe, say Iowa and Manitoba, and that is possible put the results next to each other and to declare the care given in Iowa better or worse than, or equivalent to, that provided in Manitoba. Granted, no study will ever be perfect (one must ensure, for example, that one is not comparing 80-year-old patients in Iowa to 40-year-old patients in Manitoba). But that is why it is a good idea to examine numerous studies, not just one. We did that.

The sole thread of argument Mr. Johnson offers for his claim that Canada and America are “so different” is his assertion that Canadian politicians are more insulated from public pressure than US politicians are. We have no idea how Mr. Johnson would support such a statement. We suspect the reverse is true, especially if the issue in question is health care. We believe the enormous mismatch of resources between American patients on the one hand and the AMA-hospital-HMO-pharmaceutical alliance provides far more insulation from public pressure to the US Congress than Canadian politicians enjoy. In fact, we believe Canadians have a single-payer system precisely because their politicians are less insulated than American politicians are.

Mr. Johnson identifies himself as the editor of a newsletter that advises “hospital strategists.” We hope his next delivery of words to these “strategists” meets with no mishaps.

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